The Pararectus approach for anterior intrapelvic management of acetabular fractures: an anatomical study and clinical evaluation

A new anterior intrapelvic approach for the surgical management of displaced acetabular fractures involving predominantly the anterior column and the quadrilateral plate is described. In order to establish five 'windows' for instrumentation, the extraperitoneal space is entered along the lateral border of the rectus abdominis muscle. This is the so-called 'Pararectus' approach. The feasibility of safe dissection and optimal instrumentation of the pelvis was assessed in five cadavers (ten hemipelves) before implementation in a series of 20 patients with a mean age of 59 years (17 to 90), of whom 17 were male. The clinical evaluation was undertaken between December 2009 and December 2010. The quality of reduction was assessed with post-operative CT scans and the occurrence of intra-operative complications was noted. In cadavers, sufficient extraperitoneal access and safe instrumentation of the pelvis were accomplished. In the patients, there was a statistically significant improvement in the reduction of the fracture (pre- versus post-operative: mean step-off 3.3 mm (sd 2.6) vs 0.1 mm (sd 0.3), p < 0.001; and mean gap 11.5 mm (sd 6.5) vs 0.8 mm (sd 1.3), p < 0.001). Lesions to the peritoneum were noted in two patients and minor vascular damage was noted in a further two patients. Multi-directional screw placement and various plate configurations were feasible in cadavers without significant retraction of soft tissues. In the treatment of acetabular fractures predominantly involving the anterior column and the quadrilateral plate, the Pararectus approach allowed anatomical restoration with minimal morbidity related to the surgical access.

Die operative Behandlung der Azetabulum-T-Fraktur über eine chirurgische Hüftluxation oder einen Stoppa-Zugang. [Operative treatment of T-type fractures of the acetabulum via surgical hip dislocation or Stoppa approach]

OBJECTIVE: Anatomic reduction and stable fixation by means of tissue- preserving surgical approaches. INDICATIONS Displaced acetabular fractures. Surgical hip dislocation approach with larger displacement of the posterior column in comparison to the anterior column, transtectal fractures, additional intraarticular fragments, marginal impaction. Stoppa approach with larger displacement of the anterior column in comparison to the posterior column. A combined approach might be necessary with difficult reduction. CONTRAINDICATIONS Fractures > 15 days (then ilioinguinal or extended iliofemoral approaches). Suprapubic catheters and abdominal problems (e.g., previous laparotomy due to visceral injuries) with Stoppa approach (then switch to classic ilioinguinal approach). SURGICAL TECHNIQUE: Surgical hip dislocation: lateral decubitus position. Straight lateral incision centered over the greater trochanter. Entering of the Gibson interval. Digastric trochanteric osteotomy with protection of the medial circumflex femoral artery. Opening of the interval between the piriformis and the gluteus minimus muscle. Z-shaped capsulotomy. Dislocation of the femoral head. Reduction and fixation of the posterior column with plate and screws. Fixation of the anterior column with a lag screw in direction of the superior pubic ramus. Stoppa approach: supine position. Incision according to Pfannenstiel. Longitudinal splitting of the anterior portion of the rectus sheet and the rectus abdominis muscle. Blunt dissection of the space of Retzius. Ligation of the corona mortis, if present. Blunt dissection of the quadrilateral plate and the anterior column. Reduction of the anterior column and fixation with a reconstruction plate. Fixation of the posterior column with lag screws. If necessary, the first window of the ilioinguinal approach can be used for reduction and fixation of the posterior column. POSTOPERATIVE MANAGEMENT: During hospital stay, intensive mobilization of the hip joint using a continuous passive motion machine with a maximum flexion of 90 degrees . No active abduction and passive adduction over the body's midline, if a surgical dislocation was performed. Maximum weight bearing 10-15 kg for 8 weeks. Then, first clinical and radiographic follow-up. Deep venous thrombosis prophylaxis for 8 weeks postoperatively. RESULTS: 17 patients with a mean follow-up of 3.2 years. Ten patients were operated via surgical hip dislocation, two patients with a Stoppa approach, and five using a combined or alternative approach. Anatomic reduction was achieved in ten of the twelve patients (83%) without primary total hip arthroplasty. Mean operation time 3.3 h for surgical hip dislocation and 4.2 h for the Stoppa approach. Complications comprised one delayed trochanteric union, one heterotopic ossification, and one loss of reduction. There were no cases of avascular necrosis. In two patients, a total hip arthroplasty was performed due to the development of secondary hip osteoarthritis.

Teaching video neuroimages: Beevor sign: when the umbilicus is pointing to neurologic disease

A 57-year-old man with genetically proven facioscapulohumeral muscular dystrophy (FSHMD 1A) demonstrated Beevor sign (video on the Neurology Web site at www.neurology.org). The upward movement of the umbilicus in a supine patient flexing the neck or sitting up is named after the British neurologist Charles Edward Beevor (1854-1908). He described a "marked elevation of the umbilicus in the act of sitting up" due to a paralyzed infraumbilical part of the rectus abdominis muscle, indicating a lesion of the spinal cord between the segments T10 and T12 or its nerve roots.(1) Beevor sign may also be present, as in our patient, in myopathies affecting the abdominal muscles, particularly in FSHMD, in which predominant involvement of the lower part of the rectus abdominis muscle is typical.(2).

Historia anatomico-medica, sistens numerosissima cadaverum humanorum extispicia quibus in apricum venuit genuina morborum sedes, horumque reserantur causae, vel patent effectus ... /

Contiene: Liber primus: Laesiones internas abdominis -- Liber secundus: Laesiones internas pectoris [sectio prima]

Sitting posture affects pelvic floor muscle activity in parous women: An observational study

Question Do different sitting postures require different levels of pelvic floor and abdominal muscle activity in healthy women? Design Observational study. Participants Eight parous women with no pelvic floor dysfunction. Outcome measures Bilateral activity of pelvic floor muscles (assessed vaginally) and two abdominal muscles, obliquus internus abdominis and obliquus externus abdominis, during three sitting postures. Results There was a significant increase in pelvic floor muscle activity from slump supported sitting (mean 7.2% maximal voluntary contraction, SD 4.8) to both upright unsupported sifting (mean 12.6% maximal voluntary contraction, SD 7.8) (p = 0.01) and very tall unsupported sitting (mean 24.3% maximal voluntary contraction, SD 14.2) (p = 0.004). Activity in both abdominal muscles also increased but did not reach statistical significance. Conclusion Both unsupported sitting postures require greater pelvic floor muscle activity than the supported sitting posture.

Increased expression of proteasome subunits in skeletal muscle of cancer patients with weight loss

Atrophy of skeletal muscle is common in patients with cancer and results in increased morbidity and mortality. In order to design effective therapy the mechanism by which this occurs needs to be elucidated. Most studies suggest that the ubiquitin-proteasome proteolytic pathway is most important in intracellular proteolysis, although there have been no reports on the activity of this pathway in patients with different extents of weight loss. In this report the expression of the ubiquitin-proteasome pathway in rectus abdominis muscle has been determined in cancer patients with weight loss of 0-34% using a competitive reverse transcriptase polymerase chain reaction to measure expression of mRNA for proteasome subunits C2 and C5, while protein expression has been determined by western blotting. Overall, both C2 and C5 gene expression was increased by about three-fold in skeletal muscle of cachectic cancer patients (average weight loss 14.5 ± 2.5%), compared with that in patients without weight loss, with or without cancer. The level of gene expression was dependent on the amount of weight loss, increasing maximally for both proteasome subunits in patients with weight loss of 12-19%. Further increases in weight loss reduced expression of mRNA for both proteasome subunits, although it was still elevated in comparison with patients with no weight loss. There was no evidence for an increase in expression at weight losses less than 10%. There was a good correlation between expression of proteasome 20Sα subunits, detected by western blotting, and C2 and C5 mRNA, showing that increased gene expression resulted in increased protein synthesis. Expression of the ubiquitin conjugating enzyme, E214k, with weight loss followed a similar pattern to that of proteasome subunits. These results suggest variations in the expression of key components of the ubiquitin-proteasome pathway with weight loss of cancer patients, and suggest that another mechanism of protein degradation must be operative for patients with weight loss less than 10%. © 2004 Elsevier Ltd. All rights reserved.

The Hall-Findlay mammaplasty pattern for skin-sparing mastectomy. Case report

We present an application of the Hall-Findlay mammaplasty skin pattern for skin-sparing mastectomy (SSM). This is a simplified vertical reduction mammaplasty. Vertical reduction mammaplasty is the procedure advised for patients with moderator or large ptotic breasts, who wish to have a simultaneous contra-lateral breast reduction/mastopexy at the time of SSM for cancer or prophylactic mastectomy. It is particularly suitable for breast reconstruction with autologous tissue in the form of free transverse rectus abdominis myocutaneous (TRAM), deep inferior epigastric artery perforator (DIEP) and extended latissimus dorsi (ELD) flaps.

Neustonic distribution of decapod planktonic stages and competence of brachyuran megalopae in coastal waters

Settlement rate may not reflect larval supply to coastal waters in different marine invertebrates and demersal fishes. The importance of near-shore oceanography and behaviour of late larval stages may be underestimated. The present study conducted neustonic sampling over station grids and along full-length transects at two embayments in south-eastern Brazil to (1) compare diurnal and nocturnal occurrence of most frequent decapod stages to assess their vertical movements, (2) describe the formation of larval patches and (3) measure competence of crab megalopae according to their distance to recruitment grounds. Several shrimp species apparently undergo a diel vertical migration, swimming crab megalopae showed no vertical movements and megalopae of the intertidal crab Pachygrapsus transversus revealed a reversed vertical migration. During the day, crab megalopae aggregated in convergence zones just below surface slicks. These larvae consisted of advanced, pre-moult stages, at both mid-bay and near-shore patches. Competence, measured as the time to metamorphosis in captivity, was similar between larval patches within each taxon. Yet, subtidal portunids moulted faster to juveniles than intertidal grapsids, possibly because they were closer to settlement grounds. Megalopae of Pachygrapsus from benthic collectors moulted faster than those from bay areas. These results suggest that alternative vertical migration patterns of late megalopae favour onshore transport, and actual competence takes place very close to suitable substrates, where larvae may remain for days before settlement. Lack of correlation between larval supply and settlement for Pachygrapsus suggests that biological processes, besides onshore transport, may play an important role in determining settlement success of coastal crabs.

A field study to describe diel, tidal and semilunar rhythms of larval release in an assemblage of tropical rocky shore crabs

Available information on the larval release rhythms of brachyurans is biased to temperate estuarine species and outcomes resulting from some sort of artificial manipulation of ovigerous females. In this study we applied field methods to describe the larval release rhythms of an assemblage of tropical rocky shore crabs. Sampling the broods of ovigerous females of Pachygrapsus transversus at two different shores indicated a spatially consistent semilunar pattern, with larval release maxima around the full and new moon. Yet, synchronism between populations varied considerably, with the pattern obtained at the site exposed to a lower wave action far more apparent. Breeding cohorts at one of the sampled shores apparently belonged to actual age groups composing the ovigerous population. The data suggest that these breeding groups release their larvae in alternate syzygy periods, responding to a lunar cycle instead of the semilunar pattern observed for the whole population. For the description of shorter-term rhythms, temporal series at hour intervals were obtained by sampling the plankton and confinement boxes where ovigerous females were held. Unexpectedly, diurnal release activity prevailed over nocturnal hatching. Yet, only grapsids living higher on the shore exhibited strong preferences over the diel cycle, with P. transversus releasing their larvae during the day and Geograpsus lividus during the night. The pea crab Dissodactylus crinitichelis, the spider crab Epialtus brasiliensis and a suite of xanthoids undertook considerable releasing activity in both periods. Apart from the commensal pea crab D. crinitichelis, all other taxa revealed tide-related rhythms of larval release, with average estimates of the time of maximum hatching always around the time of high tides; usually during the flooding and slack, rather than the ebbing tide. Data obtained for P. transversus females held in confinement boxes indicated that early larval release is mostly due to nocturnal hatching, while zoeal release in diurnal groups took place at the time of high tide. Since nocturnal high tides at the study area occurred late, sometimes close to dusk, early release would allow more time for offshore transport of larvae when the action of potential predators is reduced.

Source populations in coastal crabs: parameters affecting egg production

Benthic marine invertebrates may form metapopulations connected via propagule dispersal. Conservation efforts often target potential source coastlines to indirectly benefit areas depending on allochthonous offspring production. Besides population density, adult size structure, sex ratio, brooding frequency and the proportion of breeding individuals may significantly influence the reproductive output of benthic populations, but these effects have seldom been tested. We used rocky shore crabs to assess the spatial variability of such parameters at relevant scales for conservation purposes and to test their consistency over 2 consecutive years; we then used the data to address whether bottom-up processes or biological interactions might explain the patterns observed. We decomposed egg production rates into their components for the 2 most abundant brachyuran species inhabiting the intertidal rocky habitat. Adult density and brooding frequency varied consistently among shores for both species and largely explained the overall spatial trends of egg production. Temporally consistent patterns also included among-shore differences in the size of ovigerous females of the grapsid Pachygrapsus transversus and between-bay differences in the fecundity of the spider crab Epialtus brasiliensis. Sex ratio was remarkably constant in both. We found no positive or negative correlations between adult density and brooding frequency to support either the existence of a component Allee effect (lack of mate encounters) or an effect of intra-specific competition. Likewise, shore-specific potential growth in P. transversus does not negatively correlate with frequency of ovigerous individuals, as would be expected under a critical balance between these 2 processes. The patterns observed suggest that bottom-up drivers may best explain spatial trends in the reproductive output of these species.

Stomach fullness modulates prey size choice in the frillfin goby, Bathygobius soporator

Behaviours related to foraging and feeding in predator-prey systems are fundamental to our understanding of food webs. From the perspective of a predator, the selection of prey size depends upon a number of factors including prey vulnerability, prey size, and the predator's motivation to eat. Thus, feeding motivation and prey visual cues are supposed to influence predator decisions and it is predicted that prey selection by visual cues is modulated by the predator's stomach fullness prior to attacking a prey. This study was conducted using an animal model from the rocky shores ecosystem, a predatory fish, the frillfin goby Bathygobius soporator, and a benthic prey, the mottled shore crab Pachygrapsus transversus. Our results demonstrate that frillfin gables are capable of visually evaluating prey size and that the size evaluation process is modulated by the level of stomach fullness. Predators with an empty stomach (0% fullness) attacked prey that was larger than the predicted optimal size. Partially satiated predators (50% stomach fullness) selected prey close to the optimal size, while fully satiated predators (100% stomach fullness) showed no preference for size. This finding indicates an integrative response of the predator that depends on the input of both internal and external sensory information when choosing prey. Predator perceptions of visual cues (prey size) and stomach fullness modulate foraging decisions. As a result, a flexible feeding behaviour emerges, evidencing a clearly adaptive response in line with optimal foraging theory predictions. (C) 2012 Elsevier GmbH. All rights reserved.